MDMA's cultural baggage - cabin or hold?
MDMA - the love drug
In the late 80s and through the 90s, 3,4 methylenedioxymethamphetamine (MDMA) cut its cultural teeth under the monikers of ‘Ecstasy’ and ‘Molly’. It was known to be the main psychotropic sidekick of the rave and club scene in Europe and The States, and conservative corners of society were none too pleased about this.
What is less well known is that this period of ‘loved up’ recreational use was preceded by a much more low-key epoch of clinical research and experimentation - during which time MDMA showed promise as a deeply useful psychotherapeutic adjunct.
As the current pharmacological mainstays for the treatment of psychological trauma falter in a time of unprecedented need, scientific eyes and minds have again been turning to this compound as a potential tool for the treatment of mental health disorders such as addiction, depression, anxiety and PTSD. The key question about the future status of this drug may however revolve less around issues of efficacy and more around whether or not its negative cultural weight exceeds the baggage allowance of mainstream society.
THROUGH GRITTED TEETH
Imagine the following scenario. You wake up at 2.37am feeling as though Zeus himself has sent a lightening bolt through the right-hand side of your head. An eye watering pain has announced itself, burrowing out from the core of your upper right canine tooth - the worst toothache imaginable. Unbeknownst to you, the pulp inside this tooth has become engorged and inflamed, and is now beating against the walls of its little enamel prison, with implacable rage.
You are clamouring at the door of the local dental surgery at first light, seeking deliverance from this pain. After a curt confirmation that the canine is indeed the culprit the dentist informs you that the tooth itself can be saved and remain in situ - all that must happen is the offending material at the centre of the tooth – the pulp - needs to be ‘extirpated’. He says he can start a procedure right away, which will most likely return you to relative comfort. All he must do today is simply drill a small, relieving hole in the back of the tooth and take out the offending material.
This will have to be performed without any anaesthetic.
You baulk, but the pain is so insistent and so acute that you feel you must try.
The dentist approaches with the drill, and your knuckles whiten as your fingernails dig into the armrests.
Could you hold still? Would the first contact with the drill cause you to pass out? Even if you could maintain consciousness, could you trust yourself not to lurch or scream, thus making the dentists’ procedural work useless and ineffective?
When it comes to the treatment of psychological trauma this scenario is pretty much analogous to the current state of affairs in psychology and psychiatry.
The role of local anaesthetic in dentistry is merely one of treatment facilitation, allowing dentists to routinely ‘get at’ the aetiological core of the pain they treat. Such a standardised tool is not currently or routinely available during the therapeutic process.
Psychological trauma (which morphs traumatised children into emotionally bewildered adults with demoralising fidelity) has of course more complicated roots than toothache, but, just like toothache, there is a long and broad consensus about what is the most effective way to treat it;
The most effective current method to approach anything resembling a ‘cure’ of psychological trauma involves imaginal and voluntary exposure to the feared stimuli (e.g. difficult thoughts, recollections and emotions associated with the trauma) and the subsequent cognitive re-processing of these stimuli into more adaptive frames of reference.
If a skilled therapist guides a motivated and capable client on how to safely retrieve and reprocess traumatic psychic content, then that person stands a solid chance of moving past the trauma and living a more emotionally balanced life. The problem is that not everybody can marshall such resources – approximately half of current PTSD sufferers exhibit what is known as ‘treatment resistance’* which means that they are overwhelmed and traumatised anew by re-encountering their trauma. For this sub-group, therapy does not appear to be effective at treating their PTSD, because they simply cannot engage with the process.
Even talented therapists are about as likely to ‘get at’ such clients’ excruciating thoughts, memories and emotions (associated with, say, the violent rape they experienced last year, or the abusive childhood they endured), as a dentist is likely to get anywhere near your un-anesthetised toothache.
The efficacy of the planned treatment in either scenario is rendered moot if one cannot reliably cultivate an environment where such a potentially curative treatment can be executed.
What would happen if it transpired that half of the population was having to undergo painful dental surgery without any cover of anaesthetic? I would posit there would be an exhaustive and collective effort to explore every possible avenue to ensure patient comfort ‘intra procedure’ so to speak.
There would be dead ends and false dawns, and other silos of expertise would likely be recruited by the dental industry to help them figure out this problem. What I am certain of is that the overriding culture would not be one of apathetic acceptance of such a statistic.
In the same way as we would not be content to flip a coin and take our chances before going under the dentist’s drill, we should not be content to let sufferers of psychological trauma do the same when they attempt to engage in therapy. They deserve better than to be condemned to indefinite and palliative courses of treatment.
CREATING SPACE - NOT NUMBNESS
What I must make absolutely explicit is that the analogy here is not to MDMA being a potentially ‘numbing’ tool for psychiatric disorders such as trauma, but rather a tool that could potentially create optimal conditions for effective treatment - in the same way that local anaesthetic has done for the practice of dentistry. My subsequent blog posts will unpack the idiosyncratic qualities of MDMA that render it an almost ‘bespoke’ tool to be used for the facilitation of the treatment of psychological trauma.
Similarly, what I must also make explicit is that I am not proposing that the roots of psychological suffering are so easily circumscribed or paternalistically treated as in the case of a root canal procedure - my goal with such analogy is to simply provide you with perhaps a more visceral understanding of how a bruised psyche can cause someone as much suffering as the worst toothache, but that, like toothache, the suffering oftentimes cannot be abated without the use of a an a priori , placatory tool.
If psychiatry cannot reliably ‘hold the space’ for traumatised clients in a state of antecedent emotional security, is it perhaps no wonder that success rates for therapy are as poor as they are?
MDMA – TAILOR MADE FOR THERAPY?
So why is it that in certain clinical and academic quarters there is such a building sense of excitement around MDMA? It all has to do with the unique and somewhat unusual suite of effects MDMA can have on the traumatised individual. At the level of the receptors in the brain, it reduces anxiety and depression, whilst paradoxically increasing both relaxation and arousal - all of which can actually create optimal conditions for successful talk therapy to occur. This is because the needle of lucid engagement can be threaded between the excessive fear and hyper-vigilance (so characteristic of conditions such as PTSD) on the one hand and dissociation and sedation (so characteristic of many current psychiatric mainstays of treatment) on the other.
Furthermore, complicated hormonal effects and regional brain changes affected by MDMA create an emotional ‘wash’ of trust and love (there really isn’t more phenomenologically accurate a word to use) toward the therapist - which appears to be extraordinarily helpful in facilitating something known as ‘therapeutic rapport’, which has been shown to be perhaps the most important metric for successful therapeutic outcomes.
MDMA’s CULTURAL BAGGAGE – CABIN OR HOLD?
Because the MDMA experience is not typically characterised by flagrant hallucination, its road to integration into mainstream mental health treatment protocols may be freer of the more intense, ‘Apollonian’ societal scrutiny that its more ethereal stablemates (namely LSD and psilocybin) are likely to undergo. MDMA-assisted psychotherapy is much more conducive for integration into the Western ‘high street’ model than, say, a shamanic ritual with ayahuasca is ever likely to be. An astute calculation of the likelihood of such a differential in terms of widespread ‘palatability’ of MDMA assisted psychotherapy versus more classic psychedelics is the likely explanation for why the Multidisciplinary Mssociation for Psychedelic Studies (MAPS) is currently focussing their efforts on the de-scheduling of MDMA from an illicit substance with no noted categorical medical uses to one of breakthrough therapy fast racked for potential FDA approval.
In the third wave of psychedelics, MDMA-assisted psychotherapy is likely to be the first through the wall of truly mainstream culture – whether or not it will end up bloodied or lauded as a result, remains to be seen.
* Hoskins MD, Pearce J, Bethell A, et al. Pharmacotherapy for post-traumatic stress disorder: a systematic review and meta-analysis. Br J Psychiatry 2015. 2014;206(2):93–100.